Quality Account 2010/11 - James Paget University Hospitals

James Paget University Hospitals 

NHS Foundation Trust 

Quality Account 

2010/11 

Toward excellent Where you quality come care, first together

Foreword 

Statement on Quality by Chief Executive 

The year has featured both achievement and challenge for the Trust across 

all service areas, with major developments set against an increasing demand 

for healthcare in our community. The Trust and its staff have responded 

strongly to meet the need for change and improvement. 

There has been an increased demand for emergency healthcare throughout 

the year, with particularly high levels of activity during the winter months. We 

always plan for an increase at this time but the surge in January and 

February was extreme and unusual. All healthcare providers experienced extreme 

emergency demand during this period which led to extra patients coming to acute hospitals. 

The level of demand contributed to some patients having a poor experience in several of our 

clinical areas, which led to concerns being identified. Some wards had particularly high 

numbers of patients who required assisted feeding and/or increased supervision which wards 

with standard nursing ratios would find difficult to manage. A programme of actions is now 

underway to ensure that high quality essential care can be maintained at all times. Part of 

this programme will deliver enhanced staffing levels, particularly at meal times. 

The Essential Care Project brings renewed focus on the wellbeing and fundamental care of 

patients and relatives during a hospital stay. This work supports the maintenance of high 

quality care at all times, whilst meeting high demand across the system. There is also work 

ongoing to aid the care of dementia patients who require acute medical and surgical 

intervention to make their experience better and recovery quicker, giving quality and 

efficiency benefits. 

The Leading Improvement in Patient Safety scheme (LIPS) has been implemented and well 

established. Further development of safety across 10 key metrics remains a Trust objective 

for the coming year. There have already been improvements including VTE assessment, 

patient falls and pressure sores. The Patient Experience project has greatly expanded to 

include patient feedback, Experience Based Design Group and the incorporation of specific 

issues from regular Patient Story presentations to the Board of Directors. 

During the year our Maternity Services achieved Level 2 status against the new Clinical 

Negligence Scheme for Trusts (CNST) standards, reflecting the quality service provided for 

mothers and babies locally. 

Over the year the Trust has achieved its financial and quality targets with the exception of 18 

week waits for 100% of cases. The exceptional winter demand unfortunately meant that the 

elective surgery programme was affected, with some specialties not meeting this target. The 

response of staff in all departments to deliver services against a difficult background has 

been recognised and is greatly appreciated by the Board, Governors and our patients. 

The Trust has worked closely with partner organisations to develop new ways of working 

across health and social care provision. This work forms a key part of meeting the funding 

challenge in the public sector. Our staff have participated in this work, giving important 

clinical input to the service changes. The commitment of staff has been truly commendable 

during the year and I acknowledge the great contribution and achievement they have made. 

We have much to accomplish during the coming year to ensure that we continue to meet the 

needs of our community. Together we can take forward services and developments, building 

on those achieved during the last year. 

Wendy Slaney, Chief Executive 

James Paget University Hospitals NHS Foundation Trust 

Quality Account 2010/11 Page 1 of 62

Contents 

Page 

Foreword by Chief Executive 1 

Part 1 

Introduction 3 

Statement of Directors’ Responsibilities 6 

Part 2 

Priorities for 2010/11 7 

Board Statements of Assurance 17 

Review of Services 18 

Participation in Clinical Audits 19 

NICE Compliance 26 

Research 27 

Data Quality 27 

NHS Number and GMC coding validity 28 

Information Governance Toolkit 28 

Clinical Coding Error Rate 29 

What others say about the Trust 30 

Part 3 

Review of Quality Performance 31 

Patient Safety 31 

Clinical Outcomes and Effectiveness 43 

Patient Experience 46 

Endorsement 59 

Glossary of abbreviations 61 




Quality Account 2009/10 

Part 1 

1 Introduction 

Welcome to the third Quality Account report for James Paget University Hospitals NHS 

Foundation Trust. Quality Accounts are a means to improve organisational accountability, to 

enable review of services and identify areas for improvement and to demonstrate change. 

They provide an opportunity for providers of healthcare to work with clinicians to rigorously 

analyse the quality of care that is being delivered in order to assure commissioners, patients 

and the public that trust boards are continuously scrutinising the quality of their services. 

Quality Accounts are also an opportunity to drive forward our local quality improvement plans 

and to be accountable to the public and stakeholders for these improvements. 

This year has again seen a period of unprecedented demand for the Trust’s services; there 

has been a 5.2% increase in emergency admissions and a 1.7% increase in Accident and 

Emergency (A&E) attendances over the year; and yet we have still provided high quality care 

for our patients and are continuing to strive to improve services further. During 2010/11 we 

cared for the following numbers of patients: 

Elective admissions 29,590 

Emergency admissions 26,682 

Day cases 24,147 

1 st outpatient appointments 65,206 

Follow up outpatient appointments 162,910 

A&E attendances 65,665 

This equates to an average of 512 emergency admissions each week (73 each day) and an 

average of 1,260 attendances each week (180 each day) at our Accident and Emergency 

Department. To achieve this, the Trust has utilised 9,076 escalation bed 1 days. This equates 

to an average of 25 escalation beds per day this year with the Trust on ‘Black Alert’ 2 on 131 

occasions. In order to appropriately care for emergency admissions to the Trust we have 

postponed nearly 600 operations this year. Furthermore, our society is changing with our 

local population living longer. 

An additional factor we need to highlight is that our local population is living longer. The area 

of Great Yarmouth and Waveney has a greater proportion of older people than England or 

East of England averages, a smaller proportion of working age people between 20 and 50 

and a smaller proportion of children under 10. The population is forecast to age, with the 65+ 

age band likely to increase the most in future years. 

1 Escalation beds: extra beds put in place to cope with unexpected increase in demand. 

2 Black alert: The status of the hospital when it is full to capacity, escalation beds are in use, patients are waiting 

in A&E for beds, routine surgery is cancelled and the Trust is working with community partners to discharge 

patients. 



The old and the very young are known to increase demand on health. This Quality Account 

summarises some of the quality achievements and initiatives undertaken throughout 

2010/11, despite all of the pressures highlighted above. It demonstrates our continued 

commitment to the three key quality drivers: 

1. Patient Safety; 

2. Clinical Outcomes and Effectiveness; 

3. Patient Experience. 

This report will be published on the NHS Choices website and the Trust’s own website by 30 

June 2011. The report can be made available in different languages and formats if required. 

Please contact Anna Hills, Assistant Director of Governance, Safety and Compliance on 

(01493) 453684, anna.hills@jpaget.nhs.uk. 

If you would like to provide feedback regarding this Quality Account or make suggestions for 

the content of future years’ reports please contact the Assistant Director of Governance, 

Safety and Compliance as above. 

Please also see the James Paget University Hospitals NHS Trust Annual Report 2010/11 

which can be obtained from the Trust website or the Trust Secretary ann.filby@jpaget.nhs.uk 

from August 2011. 

Trust Objectives 2011/12 

The Trust has developed a five year strategy through to 2014/15. 

This strategy outlines our vision for continuing to work towards excellent quality care set out 

in four key priorities for the Trust in the coming five years; 

1 Maintaining and strengthening our core services to achieve year onyear 

improvements in clinical, operational and financial performance of the acute and 

community services that form the backbone of our Trust. 

2 Meeting the comprehensive needs of our high risk population. 

We aim to take a proactive role in managing and delivering care pathways for growing 

patient populations, in particular the elderly and those suffering from long term 

conditions. This includes working in partnership with others to address the needs of 

the community and support NHS Great Yarmouth and Waveney in reducing health 

inequalities. 

3 Enhancing the overall experience of our patients to ensure all patients of the Trust 

experience high quality care in a professional environment, treated with dignity and 

respect. Listening to the experience of our patients will be key to further improving our 

services. 

4 Being an excellent employer. We want to be recognised as an employer that is 

committed to the development of our staff, recruiting the most capable and dedicated 

employees who share our vision for excellent patient care. Clear and consistent 

leadership for our staff and investment in their ongoing training and development are 

important commitments we aim to deliver during this period. 



We have ensured our strategy is in line with the direction and priorities set out in national, 

regional and local health strategies; Lord Darzi’s Next Stage Review, the NHS East of 

England’s ‘Towards the Best, Together’ and NHS Great Yarmouth and Waveney’s local 

strategy. 

We believe that pursuing this strategy will result in excellent services that will deliver better 

outcomes for the people of Great Yarmouth and Waveney and will contribute towards 

building a healthier community for the future. 

The Trust has agreed a number of strategic objectives for the coming year which will promote 

delivery of the five year strategy and directly cascade to team and individual objectives: 

1. Improve the care and experience of patients, with a specific focus on older people 

and those with dementia, by working internally and with partner agencies. 

2. Deliver further improvements against the 10 key metrics of the Leading Improvement 

in Patient Safety scheme across the Trust, e.g. infection and falls preventions 

3. Continue to implement a range of transformation and quality improvements across all 

care pathways, with particular focus on length of stay. 

4. Deliver all financial targets. 

5. Demonstrate further progress towards a reduction in carbon emissions at the Trust of 

20% by 2015. 

6. Achieve national performance standards that underpin the provision of excellent 

services to our community. 

These objectives to be supported by a framework of educational and development 

support for staff. 



Statement of directors' responsibilities in respect of the quality accounts 

The directors are required under the Health Act 2009 and supporting regulations to prepare 

Quality Accounts for each financial year. In preparing these accounts, directors are required 

to take steps to satisfy themselves that: 

• the Quality Accounts present a balanced picture of the NHS foundation trust’s 

performance over the period covered; 

• the performance information reported in the Quality Accounts is reliable and accurate; 

• there are proper internal controls over the collection and reporting of the measures of 

performance included in the Quality Accounts, and these controls are subject to 

review to confirm that they are working effectively in practice; 

• the data underpinning the measures of performance reported in the Quality Accounts 

is robust and reliable, conforms to specified data quality standards and prescribed 

definitions, and is subject to appropriate scrutiny and review; and 

• the Quality Accounts have been prepared in accordance with relevant requirements 

and guidance issued by Monitor. 

The directors confirm to the best of their knowledge and belief that they have complied with 

the above requirements in preparing the Quality Accounts. 

........................................................................................... Chairman 

........................................................................................… Chief Executive 



Part 2 

Priorities for improvement 2011/12 

Our Quality Strategy continues to focus on the three key areas of patient safety, clinical 

outcomes and effectiveness, and patient experience. Hence, our four key priorities for 

2011/12 are as follows: 

• Patient safety – Reduction in In-Patient Falls; 

• Patient safety – Reduction in standardised mortality rates; 

• Patient Experience – To embed the Trust Values; and 

• Clinical Outcomes and Effectiveness – Achievement of the CQUIN goals. 

Delivery of these priorities will be overseen by the Transformation Board which is responsible 

for delivery of the productivity and effectiveness, patient safety and patient experience 

agendas via three project streams. Each project stream is driven by a dedicated project 

director and a clinical champion who oversees delivery of an action plan, underpinned by 

‘lean’ methodology. 

The Transformation Board monitors delivery of the action plans and reports directly to the 

Board of Directors of the Trust as well as contributing to the system wide Great Yarmouth 

and Waveney Transformation Board and the East of England arrangements. 

Priority 1a: Patient safety – Reduction in In-Patient Falls 

AIM: To reduce in-patient falls by 10% 

This will be measured via the Patient Safety Programme key metrics. The percentage 

reduction in falls will be measured against the 2010/11 baseline using the per 1000 bed days 

calculation. 

Executive Sponsor: Director of Nursing 

Responsible officer: Patient Safety Project Director 

During 2010/11 there were 1063 in-patient falls across the Trust compared to 1149 in 

2009/10 (7.5% reduction). Nationally there were 283,438 slips, trips and falls reported to the 

National Patient Safety Agency (NPSA) between October 2008 and September 2009. Inpatient 

falls continued to be the Trust’s highest category of adverse incidents reported during 

2010/11. 

During 2010/11 there was a Local Improvement Aim linked to a CQUIN 3 to achieve: 

1. 20% reduction in the number of in-patient falls. 

2. The use of risk assessments across the Trust to ensure patients are appropriately 

assessed and preventative measures introduced as a result of their level of risk of falls. 

3 The Commissioning for Quality and Innovation (CQUIN) payment framework is a national framework for locally agreed quality 

improvement schemes. 



Current position: 

Patient Falls 

120 

111 

Monthly Total (Total = 1063) 

Trajectory 

111 

Number of Incidents 

100 

80 

60 

40 

99 

96 

92 91 

88 

85 

83 

78 

76 76 76 76 76 76 76 76 76 76 75 76 76 

49 

20 

0 

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 

Month and Year 

During 2010/11 18 patients suffered a fracture as a result of a fall whilst in our care; 14 hip 

fractures, 1 fractured nose, 1 fractured shoulder and 2 fractured wrists. All of these incidents 

were comprehensively investigated. 

A number of significant improvements have been achieved during 2010/11 to help reduce inpatient 

falls. These include: 

• Significantly raised awareness 

• 10 Key Responsibilities for falls prevention 

• Revised documentation in all ward areas 

• Communication cascade regarding falls prevention care 

• Assistive Technology – Sensor Care Trigger Alert 

• Patient Safety Action Planning & Development Day for nursing staff 

• Dedicated resource to support the change process 

• Refocussed Trust Falls Steering Group 

• Redesign of mandatory training package and inclusion of falls prevention in induction 

• Hospital at night (H@N) team link nurse involvement to achieve promotion of the 

standards 24/7 

• Allocation of Strategic Workforce Investment Fund for Tomorrow (SWIFT) funding for 

falls prevention 

• Increased regional networking – proposal for standardised practice expectation 

across Norfolk. 

However, there remain a number of concerns including: 

• Volume of in-patient falls; 

• Volume of fractures sustained as a result of an in-patient fall; and 

• Current capacity and demand issues and perceived impact on ability to maintain 

prevention standards. 



The further reduction in in-patient falls will be achieved by embedding the 10 key 

responsibilities below: 

Case Study 1: Assistive Technology 

Technology is also a part of our falls prevention work. The Trust has recently invested in a 

sensitivity trigger alarm system called Sensor Care. 

The Sensor Care Alarm System is a device that has been developed to alert staff when a patient 

at risk of falls has moved from their bed or chair. 

The device works by having a sensitivity plate under the bed mattress or chair cushion. The 

sensitivity level on the plate is programmed in accordance with the patient’s size. When the 

patient stands up or moves sufficiently to change the sensitivity level an alert is created through 

a bleep which is specifically paired with the plate or cushion e.g. if bleep 1 alarmed, it would be 

telling you that the patient on mattress 1, is trying to get out of bed or has succeeded. This acts 

as an alert to investigate what the patient is doing and therefore reduce the level of risk of the 

patient falling if you didn’t know they were moving. 

At the current time we have enough systems to cover the top floor of the hospital. A bid is being 

developed to try to extend this to cover all areas of the hospital. Lowestoft Hospital already has 

the sensor care system in place. 



Priority 1b: Patient safety – Reduction in mortality rates 

AIM: To integrate HSMR measures into clinical and managerial 

processes 

The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that 

measures whether the death rate at a hospital is higher or lower than you would expect. Like 

all statistics, HSMRs are not perfect. If a hospital has a high HSMR, it cannot be said for 

certain that this reflects failings in the care provided by the hospital. However, it can be a 

warning sign that things are going wrong. 

The HSMR compares the expected rate of death in a hospital with the actual rate of death for 

a number of diagnoses, for example, heart attacks, strokes or broken hips. For each group 

of patients it is possible to work out how often, on average, across the whole country, they 

survive their stay in hospital. This is achieved by taking into account their age, the severity of 

their illness and other factors, such as whether they live in a more or less deprived area. This 

provides a figure for how many patients we would expect to die at each hospital. This is then 

compared with the number of patients that actually die. If the two numbers are the same, the 

hospital gets a score of 100. If the number of deaths is ten per cent less than expected they 

get a score of 90. If it is ten per cent higher than expected, they score 110. 

Care is needed in interpreting these results. Just through chance, some hospitals will have a 

higher mortality rate and some a lower rate. It is inevitable that half the hospitals will have a 

worse than average result and that some will be quite a lot worse than the average. It is 

important to focus on "outliers". These are hospitals where the results lie outside the normal 

range, or particular groups of conditions where results lie outside the normal range, for a 

particular hospital. 

An HSMR 14 point action plan has been approved by the Trust’s Board of Directors and 

Management Team, to integrate the use of HSMR data with other tools. Specialties with a 

higher than average mortality rate can understand why this has occurred and take any 

necessary steps to improve. The action plan will be owned by the Trust’s Management Team 

and progress against the actions will be monitored through the existing performance 

management processes. A regular update on progress will be provided to both the Board of 

Directors and Management Team throughout the year. 

Executive Sponsor: Medical Director 

Responsible officer: Deputy Director of Performance 

Objectives: The Trust aims to reduce its overall and specialty specific HSMR to less than 

100 throughout 2011/12. 



Current position: 

Hospital Standardised Mortality Ratio (HSMR) for 2010/11 

100 

90 

80 

70 

Relative risk 

60 

50 

40 

30 

20 

10 

0 


Actual 94 98.6 86.8 81.1 92.8 87.7 100.5 75.5 74.5 

Priority 2: Patient Experience – To embed the Trust Values 

AIM: To improve the patient experience by embedding the Trust 

values into all that we do 

This will be measured by the Trust Values Steering Group. 

Executive Sponsor: Director of Workforce and Estates 

Responsible officer: Head of Learning and Organisational Development 

The Trust has received feedback from our patients and the public via complaints, PALS 

enquiries and other sources which has indicated that at times our communications require 

improvement. 

In response to this the Trust has agreed a set of core values which it expects all staff to 

demonstrate in order to improve the experience of our patients and visitors. 

The Board is determined to see the Trust’s values as a critical and integral part of the Paget 

experience. The values must be understood by all staff and embedded in the organisation 

resulting in patients and service users experiencing these values when they are in contact 

with our staff. A steering group has been established to ensure this happens and to monitor 

progress. 

The steering group comprises key senior individuals from across the organisation including a 

Non Executive Director. It has been established to develop and implement a set of action 

plans that will ensure the Trust’s values are embedded in the organisation. It will monitor and 

evaluate the effectiveness of the action plans and report on progress to the Board during the 

year. 


Quality Account 2010/11 Page 11 of 62

Five work streams have been agreed and steering group members have responsibility for 

each area: 

• Human Resources processes and procedures 

• Internal and external Communication 

• Organisational processes and policies 

• Patient and Stakeholder experience of values 

• Leadership and values. 

The objectives for 2010/11 were: 

• 80% of employees will be able to articulate the values; 

• 50% of patients will know about our values; 

• The values will be incorporated in all people management and development 

processes; and 

• The Board will be assured that the values are integral to a patient safety 

culture. 

A baseline audit was conducted from September to December 2010 and questions on the 

values were added into the Patient Experience Tool (PET). 52% of the 696 respondents 

indicated that they knew the Trust had a set of values, however only 18% could name them. 

Staff knowledge of the values was measured in a variety of ways during March 2011, which 

included: 

• Face to face sessions with staff 

• Intranet survey 

• Paper questionnaires distributed to 300 members of staff 

• Patient experience tool situated in the staff restaurant 

• Questioning staff at training sessions and after induction. 

The total number of staff who participated or responded was 1043; 734 (86%) were able to 

articulate the values. 

The Values Steering Group will continue to function during 2011/12. The focus of the group 

will be to continue to raise awareness of the values with staff through embedding the values, 

concentrating on the behavioural change required and supporting senior managers and 

clinicians in the role modelling of the values. 

James Paget University Hospitals NHS Foundation Values: 

Putting patients first, and they will: 

Provide the best possible care in a safe clean and friendly environment, 

Treat everybody with courtesy and respect, 

Act appropriately with everyone. 

Aiming to get it right, and they will: 

Commit to their own personal development, 

Understand theirs and others roles and responsibilities, 

Contribute to the development of services 

Recognising that everyone counts, and they will: 

Value the contribution and skills of others, 

Treat everyone fairly, 

Support the development of colleagues. 

Doing everything openly and honestly, and they will: 

Be clear about what they are trying to achieve, 

Share information appropriately and effectively, 

Admit to and learn from mistakes. 



Priority 3: Clinical Outcomes and Effectiveness – Achievement of the CQUIN 

goals. 

AIM: To utilise the CQUIN scheme to drive quality improvements 

across a number of specific areas 

Achievement of the CQUINs will be monitored via the Transformation Board. 

Executive Sponsor: Medical Director 

Responsible officer: Project Lead for Effectiveness and Productivity 

The Commissioning for Quality and Innovation (CQUIN) payment framework is a national 

framework for locally agreed quality improvement schemes. It makes a proportion of provider 

income conditional on the achievement of ambitious quality improvement goals and 

innovations agreed between commissioner and provider, with active clinical engagement. 

The CQUIN framework is intended to reward excellence, encouraging a culture of continuous 

quality improvement in all providers. 

A CQUIN scheme is the locally agreed package of quality improvement goals and 

indicators, which in total, if achieved, enables the provider to earn its full CQUIN 

payment (calculated as 1.5% of the Actual Outturn Value of the provider contract in 

2011/12). A CQUIN scheme should address the three domains of quality: safety, 

effectiveness and patient experience; and reflect innovation. 

A CQUIN goal describes a quality improvement objective which is being incentivised 

through a CQUIN scheme. A goal may be measured using several indicators. 

A CQUIN indicator is a measure which determines whether a goal or an element of the 

goal has been achieved, and on the basis of which payment is made. 

CQUIN targets were agreed between the Trust and the commissioning PCT, NHS Great 

Yarmouth and Waveney, at the beginning of the financial year. Achievement of these was 

monitored throughout the year. 

The table overleaf describes achievement of the CQUINs for 2010/11 at the time of writing 

this report. The total value of the CQUIN scheme for 2010/11 was £1.8 million. 



No 

Commissioning for 

Quality and Innovation 

(CQUIN) 

CQUIN GOAL 

CQUIN INDICATOR 

Achieving 

Not Currently Achieving 

On Plan to Achieve 

Area of Concern 

1 

2 Dementia 

3 Patient Responsiveness 

4 End of Life - choice 

5 

Maternity Services user 

responsiveness 

8 Day Case Basket 

9 Reduce falls in hospital 

10 Case note audits 

Reduce avoidable death, disability and 

chronic ill health from Venousthromboembolism 

(VTE) 

Development and implementation of an 

integrated Dementia Pathway across 

mental health & learning disability, 

community and acute sectors: 

Improve response to personal needs of 

patients 

Provide Palliative and End of Life care 

using the nationally defined end of life 

care tools 

Maternity user responsiveness 

Improve rate for Audit Commission 

basket of 25 procedures performed as a 

day case 

Reducing Falls whilst in Hospital 

Mortality audits and case note reviews 

for harm events 

1. % of all adult inpatients 

who have had a VTE risk 

assessment on admission 

to hospital using the 

national tool 

2. % of inpatient & 

obstetric patients excluding 

non obstetric day cases 

who have had appropriate 

thrombopropyhlaxis 

Leading and working on 

Acute Trust elements of 

the pathway in partnership 

with all key stakeholders. 

The indicator will be a 

composite, calculated from 

5 survey questions. Each 

describes a different 

element of the overarching 

theme: “responsiveness to 

personal needs" 

1. Provision of palliative 

and EOL care using the 

nationally defined EOL 

care tools 

2. Reduction in the number 

of palliative/EOL patients 

dying in the acute care 

setting 

Introduction of ongoing 

user survey and 

subsequent audit/response 

to improve patient 

experience. 

% of all operations from 

the Audit Commission 

basket of 25 procedures 

performed as a day case 

Reduce in-patient falls by 

20% compared to 2009/10 

baseline. 

1. Baseline review: 

Mortality 100 sets of notes 

& Harm events, 40 sets of 

notes 

2. Ongoing monthly 

reviews: Mortality 20 sets 

of notes & Harm events, 20 

sets of notes. 



No 



(CQUIN) 

CQUIN GOAL 


Achieving 




11 

12 

Pressure ulcers 

Patient safety walk 

rounds 

13 C. difficile 

Measurable reduction in hospital 

acquired pressure ulcers 

Patient Safety Walkrounds – these are 

recommended by LIPS, Patient Safety 

First and IHI and are clear drivers for 

quality improvements. These would 

greatly enhance the safety culture of the 

organisation. 

Enhanced surveillance: Hosting and 

maintaining a system-wide 

register/database of C. difficile cases 

using HPA’s web-based EPIDATA 

database. 

20% reduction in the rate 

between the final indicator 

period and the 2009/10 

baseline for inpatient 

hospital acquired pressure 

ulcers 

24 patient safety 

walkrounds to be 

conducted during 2010/11 

Need to reduce C. difficile 

infections across the whole 

system. HPA guidance 

suggests whole-system 

case register of C difficile 

patients 

14 Accrediting practitioners 

15 

16 

17 

Innovation - pathways & 

delivery of care - 

Diabetes 

Participation on Clinical 

Transformation Board 

Weekend TIA carotid 

imaging 

Accrediting and ongoing supervision of 

practitioners in primary and community 

care with a special interest 

To develop and implement a dataset in 

Diabetes clinic in JPUH to support high 

quality care 

Support to clinical transformation 

strategy 

Weekend TIA service 

1. Accreditation and 

learning needs of new 

primary & community care 

practitioners supported. 

2. Ongoing supervision 

and learning needs met. 

3. Evidenced by records of 

interactions. 

Implement and utilise a 

data capture system for 

outpatient management of 

Diabetes. 

Integration and 

involvement of Trust 

clinicians in delivery of 

NHS GY&W Strategy and 

Operating Plan 

1. Percentage of high risk 

TIAs presenting at 

weekends receiving carotid 

imaging within 24 hours. 

2. Percentage of all high 

risk TIAs assessed and 

investigated within 24 

hours of first NHS contact 

(excluding admitted TIAs). 

18 

Psychological 

assessment 

To deliver access to psychological 

assessment (including cognitive 

assessment) and support for Stroke 

Proportion of Stroke 

patients who have had 

specialist psychological 

assessment or treatment 

by 6 months post stroke (at 

least 75% of which need to 

be undertaken as an 

inpatient) 



No 



(CQUIN) 

CQUIN GOAL 


Achieving 




19 Preventable strokes 

20 

21 

Stroke - managing high 

risk TIA patients 

Stroke - Direct 

admissions to stroke 

ward 

22 Stroke - Access to CT 

23 Demand Management 

The number of these patients who were 

discharged on anticoagulation or with a 

date to commence anticoagulation via 

anticoagulation team documented on 

discharge summary 

Management of high risk TIA patients - 

Clinic Appointment 

Timely access to acute stroke units 

prevents death and increases 

independence 

Access to timely imaging for eligible 

patients admitted having had a stroke 

Development and implementation of 

demand management initiatives and 

pathway redesign across primary, 

secondary, community and social care 

sectors 

Proportion of patients 

presenting with stroke with 

AF anti-coagulated on 

discharge or with clear 

plans documented in the 

discharge communication 

to commence 

anticoagulation at a 

clinically appropriate time 

post discharge 

Number of High Risk TIA 

patients investigated and 

treated within 24 hours of 

first NHS contact excluding 

those admitted 

Patients admitted within 4 

hours to the stroke unit 

Eligible patients admitted 

having had a stroke who 

receive CT within 60 

minutes of admission 

Leading and working on 

acute trust elements of the 

pathway in partnership with 

all key stakeholders 

A proportion of James Paget University Hospitals NHS Foundation Trust’s income in 

2010/11 was conditional on achieving quality improvement and innovation goals 

agreed between James Paget University Hospitals NHS Foundation Trust and any 

person or body entered into a contract, agreement or arrangement with for the 

provision of NHS services, through the Commissioning for Quality and Innovation 

payment framework. 



Board Statements of Assurance: 

Review of services 

The National Health Service (Quality Accounts) Regulations 2010 require that a number of 

statements are included within the Quality Account so that there is common content between 

providers making the accounts comparable. These statements are contained within the 

boxes which follow: 

During 2010/11 the James Paget University Hospitals NHS Foundation Trust provided and/or 

sub-contracted the NHS services listed in the table on page 18. 

The James Paget University Hospitals NHS Foundation Trust has reviewed all the data 

available to them on the quality of care in all of these NHS services. 

The income generated by the NHS services reviewed in 2010/11 represents 100% percent of 

the total income generated from the provision of NHS services by the James Paget 

University Hospitals NHS Foundation Trust for 2010/11. 

The James Paget University Hospitals NHS Foundation Trust provides services to the whole 

population of Great Yarmouth and Waveney at two locations: 

1. James Paget University Hospital; and 

2. Lowestoft Hospital. 

As well as a number of community clinics. 

The service types provided at these locations are: 

1. Acute services; 

2. Hospice services; 

3. Community healthcare services; and 

4. Dental services. 

The regulated activities which the Trust is registered to provide, as defined by the Health and 

Social Care Act 2008 (Regulated Activities) Regulations 2009 schedule 1, and carried out by 

the Trust are as follows: 

• Personal care; 

• Treatment of disease, disorder or injury; 

• Surgical procedures; 

• Diagnostic and screening procedures; 

• Maternity and midwifery services; 

• Termination of pregnancies; and 

• Family planning services. 



The services provided by James Paget University Hospitals NHS Foundation Trust include 

the following: 

Division 

Emergency 

Elective 

Women & Child Health 

Core Clinical 

Specialties and services: 

Accident and Emergency (A&E) 

General Medicine 

Gastroenterology 

Endocrinology 

Diabetes 

Haematology 

Cardiology 

Dermatology 

Nephrology and renal dialysis 

Genitourinary Medicine 

Rheumatology 

Respiratory Medicine 

General Surgery 

Vascular Surgery 

Breast Surgery 

Gastro-intestinal Surgery 

Urology 

Trauma and Orthopaedics 

Ear, Nose and Throat 

Oral Surgery 

Ophthalmology 

Gynaecology 

Obstetrics 

Maternity services 

Community midwifery 

Neonatology 

Parentcraft 

Antenatal screening 

Fertility services 

Diagnostic Imaging 

• X-ray services 

• Specialist Imaging 

• Ultrasound services 

• Mammography services 

• MRI & CT services 

Medical illustration 

Pharmaceutical services 

Lowestoft Hospital 

Care of the elderly 

GP beds 

Care of the Elderly 

Diabetic Liaison 

Clinical Measurement 

Coronary Care 

Endoscopy 

Rehabilitation 

Intensive Care Services 

Hyperbaric services 

Oncology 

Sandra Chapman Centre (day treatment 

for adults with haematological disease 

and cancer) 

Therapies e.g. physiotherapy 

Anaesthetics 

Clinical Specialties of Continence and 

Stoma Care 

Audiology 

Dental and Orthodontics 

Community Dental Services 

Pain Management 

Palliative Care 

Paediatrics 

Paediatric Surgery 

Children’s Centre 

Community Paediatric Service 

School Nursing (GY) 

Safeguarding children 

Community services 

Chemical Pathology 

Immunology and Serology 

Microbiology 

Haematology 

Blood Transfusion 

Bereavement Services 

Pharmaceutical Services 

Social Work Support 

Reviews of the quality of services provided by the Trust for all its locations and all of the 

service types and regulated activities have taken place during 2010/11. The processes used 

are described in Part 3 of this report. 

A number of external assessments were conducted during 2010/11, including: 

• Health and Safety Executive review of Microbiology laboratory; 

• National Cancer Peer Review 

• Clinical Negligence Scheme for Trusts (CNST) review of Maternity Services 

• External Quality Assessment of the Diabetic Retinal Screening Service 

• Human Fertilisation and Embryology Authority (HFEA) review of Fertility Service 

• Intensive Care Unit/High Dependency Unit peer review audits 

• Care Quality Commission Review of Support for Families with Disabled Children 

• Fire Risk Assessments Trust-wide 

• Patient Environment Action Team 

• Environmental health. 



During 2011/12 a number of further service reviews are planned which will be aligned to the 

Trust’s CQUIN targets with our commissioners and the Quality Innovation, Productivity and 

Prevention projects (QIPP). 

Participation in Clinical Audits 

During 2010/11, 33 national clinical audits and two national confidential enquiries covered NHS 

services that the James Paget University Hospitals NHS Foundation Trust provides. 

During that period James Paget University Hospitals NHS Foundation Trust participated in 88% 

(29/33) of the national clinical audits and 100% of the national confidential enquiries which it was 

eligible to participate in. 

The national clinical audits and national confidential enquiries that James Paget University Hospitals 

NHS Foundation Trust was eligible to participate in during 2009/10 are listed in the table overleaf. 

The national clinical audits and national confidential enquiries that James Paget University Hospitals 

NHS Foundation Trust participated in, and for which data collection was completed during 2010/11, 

are listed in the table on page 20. This includes the number of cases submitted to each audit or 

enquiry as a percentage of the number of registered cases required by the terms of that audit or 

enquiry 4 . 

The table overleaf describes the list of national audits drawn up by the National Clinical Audit 

Advisory Group of the Department of Health. Although national audits are not mandatory, 

Trusts are recommended to participate in those audits of services which they provide. 

The CQC uses information from national audits in its Quality and Risk Profiles to identify 

whether a Trust is at risk of not complying with the registration requirements. There is now a 

formalised process in place whereby the Clinical Effectiveness Committee reviews national 

audits to make a corporate decision whether or not participation is cost effective and 

achievable. 

4 Where this information was available at the time of reporting 



Clinical Audits 

Audit Name Applicable Trust Lead Percentage of Cases 

Submitted 

Peri - and Neonatal 

Perinatal Mortality (CEMACH) 

Neonatal intensive and special care (NNAP) 

Children 

 

 

 

Carol Mutton 100% 

Laurie Howarth 100% 

Paediatric pneumonia 

(British Thoracic Society) 

John Chapman Data collection ongoing 

Paediatric asthma 

John Chapman Data collection ongoing 


 

Paediatric fever 

Donna Wade Data collection ongoing 

(College of Emergency Medicine) 

Childhood epilepsy 

Dr Nirmal Data collection ongoing 

(RCPH National Childhood Epilepsy Audit) 

Paediatric Intensive Care (PICANet) John Chapman No participation 

Paediatric Cardiac surgery 

(NICOR Congenital Heart Disease Audit) 

Diabetes 

(RCPH) National Paediatric Diabetes Audit) 

Acute Care 

Emergency use of oxygen 


Adult community acquired pneumonia 


Non-invasive ventilation (NIV)-adults (British 

Thoracic Society) 

Pleural procedures 

(British Thoracic Society 

Cardiac Arrest 

(National Cardiac Arrest Audit) 

Vital signs in majors 

(College of Emergency Medicine) 

Adult Critical Care 

(Case Mix Programme) 

Potential donor audit 

(NHS Blood & Transplant) 

Long Term Conditions 

Diabetes 

(National Adult Diabetes Audit) 

Heavy Menstrual bleeding 

(RCOG National Audit of HMB) 

Chronic Pain 

(National Pain Audit) 

Ulcerative colitis & Crohn’s disease 

(National IBD Audit) 

Parkinson’s disease 

(National Parkinson’s Audit) 

 

 

 

 

 

 

 

 

 

 

 

 

John Chapman 

Dr Raman 

Dr Cotter 

Dr Cotter 

Dr Cotter 

Dr Cotter 

Pam Cushing 

Dr Crawfurd 

Donna Wade 

Adam Devany 

Dr Karlikowski 

Lynn Everett 

No participation 

Data collection ongoing 





65 cases submitted 

100% 

100% 

Jean Jennings 100% 

Mrs Rashid 

Dr Notcutt 

Dr DeSilva 

Dr Huston forward 

Dr Woodward 

Dr Shields 









Submitted 

COPD 

(British Thoracic Society/European Audit) 

Adult Asthma 


Bronchiectasis 


Elective Procedures 

Hip, knee and ankle replacements (National 

Joint Registry) 

Elective Surgery 

(National PROMs Programme) 

Cardiothoracic Transplantation (NHSBT UK 

Transplant Registry) 

Liver Transplantation 

(NHSBT UK Transplant Registry) 

Coronary angioplasty 

(NICOR Adult cardiac interventions audit) 

Peripheral vascular surgery 

(VSGBI Vascular Surgery Database) 

Carotid interventions 

(Carotid Intervention Audit) 

CABG and valvular surgery 

(Adult cardiac surgery audit) 

Cardiovascular disease 


Quality Account 2010/11 Page 21 of 62 

 

 

 

 

 

Dr Cotter 

Dr Cotter 

Dr Cotter 

Caroline Scarll 

Helen French 

Dr Ryding 

Dr Ryding 

Dr Ryding 

Dr Ryding 





Proms Results April 

2009 – Sept 2010 

Site 

Varicose 

Vein 

Participation 

rate JPUH 

Pre-op 

questionnaires 

51% 

Groin hernia 65.7% 

Knee 88.7% 

Hip 79.6% 

All 

75.5% 

procedures 







Familial hypercholesterolaemia (National 

Dr Ryding No participation 

Clinical Audit of Mgt of FH) 

Acute Myocardial Infarction and other ACS 

Dr Ryding Data collection ongoing 

(MINAP) 

Janet Shreeve 

Heart Failure 

(Heart Failure Audit) Janet Shreeve 100% 

Pulmonary hypertension 


(Pulmonary Hypertension Audit) 

Acute Stroke (SINAP) 


Dr George 

Stroke Care 

Evie Cooper 100% 

(National Sentinel Stroke Audit) 

Renal Disease 

Renal replacement therapy 

(Renal Registry) 

Mark Prentice 

Data included in Norfolk 

and Norwich University 

Hospitals NHS 

Foundation Trust 

return. 

Renal Transplantation Mark Prentice No participation.

(NHSBT UK Transplant Registry) 


Submitted 

Patient transport 

(National Kidney Care Audit) 

Renal Colic 

(College of Emergency Medicine) 

Cancer 

Lung cancer 

(National Lung Cancer Audit) 

Bowel Cancer 

(National Bowel Cancer Audit Programme) 

Head & Neck Cancer (DAHNO) 

Trauma 

Hip fracture 

(National Hip Fracture Database) 

Severe trauma 

(Trauma Audit & Research Network) 

Falls and non-hip fractures 

(National Falls & Bone Health Audit) 

Psychological conditions 

 

 

 

 

 

 

 

 

 

Mark Prentice 100% 

Donna Wade 

Dr Mahadevan 

Linda Hayes 

Steve Wright 

Mr Premachandra 

Tracey Church 




100% 

Louise Hebdon 100% 

Louise Hebdon 

Dr Zaidi 



Depression & anxiety 

(National Audit of Psychological Therapies) 

Kirk Lower 

Occ Health 


Prescribing in mental health services 

No participation – 

(POMH) 

Mental Health 

National Audit of Schizophrenia (NAS) No participation – 

Mental Health 

Blood Transfusion 

O neg blood use 

(National Comparative Audit of Blood 

Transfusion) 

Platelet use 

(National Comparative Audit of Blood 

Transfusion) 

 

 

Julie Jackson 

Julie Jackson 





Locally developed clinical audits are reviewed at various multidisciplinary meetings across 

the Trust. During 2010/11 the following numbers of local audits were reviewed and 

discussed at internal meetings and actions to improve clinical services were subsequently 

agreed: 

Paediatric Audit Meeting 13 

Perinatal Morbidity & Mortality Meeting 2/3 case presentations per meeting 

Emergency Clinical Governance Meeting 4 

Combined Audit Elective Division 

7 (+ Surgical Mortality Review cases) 

The following case studies provide examples of where clinical audits have directly led to 

improvements in patient services. 

Case Study 1: Re-audit Compliance with Trust Antibiotic Guideline 

Objectives 

• To investigate compliance with the Trust Antibiotic Guideline 

• To highlight any possible areas of improvement. 

Following this audit the following actions were agreed: 

Action Plan 

• Educate new doctors in the right way of prescribing antibiotics via induction training 

sessions. 

• Drug chart to be redesigned for antibiotic prescribing which would include a space for 

review date and indication for the antibiotics. 

• A separate antibiotic sticker to be trialled in EADU which indicates a review/stop date 

and the indication for prescribing. 



Case Study 2: Upper Gastrointestinal Bleed Audit 

Aim 

A re-audit of the management of Upper Gastrointestinal bleeds (UGIB) according to the 

SIGN (Scottish Intercollegiate Guidelines Network) guidelines (also adopted by Royal 

College of gastroenterology and NICE) in view of implementing Trust guidelines. 

Objectives 

100% of patients admitted with suspected upper GI bleed should meet the criteria set out 

below: 

1 Assessed using an upper GI bleed scoring system to categorise risks 

2 Observations including BP and pulse 

3 Blood tests including Hb and Urea 

4 Rectal examination performed at time of first assessment 

5 Patients scoring 0 on Blatchford score are discharged for outpatient endoscopy 

6 Clo test results clearly documented and acted on 

7 Receive early endoscopy, defined as being performed on the day or following day 

of request being made 

8 Use of proton pump inhibitors (PPIs) if there is no 24 hour endoscopy service 

available or PPI have been recommended post endoscopy by the endoscopist 

Conclusions 

• Significant improvement in use of UGIB scoring system 

• Education of junior doctors required regarding rectal examination at first 

assessment, awareness of significance of Clo Testing and treatment 

• Documentation throughout medical notes could be improved 

• Concise Trust guidelines for the management of patients admitted with Upper GI 

Bleed are required. 



Case Study 3: Patient Hospital Paper Health Records Documentation Audit 2010 

Objectives 

Comparative audit for Trust and specific areas; to highlight adherence to NHS and JPUH 

policy criteria 

Rationale: Ongoing audit (NHSLA) of correctness of Patient Paper Health Records 

Audit Sample: 5 sets of notes were reviewed per Specialty; covering 31 Specialties, out 

of a possible 46 (67%), which resulted in 319 professional entries being individually 

assessed for compliance with criteria 

Data collection: 

Data Source: 

Data Collection: 

Retrospectively 

(admissions reviewed from 10th June to 8th December 2010) 

Patient Paper Health Records 

Undertaken by Junior Doctors, Nurses and Clinic Staff 

Results compare 2008, 2009 + 2010 audits 

Conclusions 

• There has been a year on year improvement since 2008 in the quality of Health 

Care Files 

• Timings of entries is only 70% 

• All entries (including alterations/additions) identify author by reference to Nursing 

Accountability Record is only 55% 

• Common anecdotal complaints of numerous documents not filed correctly, not in 

chronological order or loose etc are untrue with 90%+ being correct. Still room for 

improvement! 

• Allergy notation has greatly improved 

Overall conclusions 

• Shows that progress made with the documentation work streams around the 

Trust and that the importance of correct documentation can now be shown to be 

a vital part of improving patient safety and patient outcomes 

Recommendations: 

• To evaluate the audit paperwork to make it easier to understand 

• To evaluate the audit process so it is embedded into the Trust and that key staff 

groups are signed up to undertake the audit work rather than the ad hoc 

approach at present 

• To disseminate the findings and create an action plan of actions and hence 

improvements in areas of need 



The Trust has a dedicated lead for National Confidential Enquiry into Patient Outcome and 

Death (NCEPOD) who provides regular reports regarding the Trust’s progress with 

implementing the recommendations from the published reports. Self assessments have 

been carried out using the NCEPOD tools and action plans are in place to ensure 

implementation of the recommendations. 

There were three confidential enquiries published by NCEPOD during 2010/11, two of which 

were applicable to the Trust: 

• Parenteral nutrition; and 

• Elective and Emergency Surgery in the Elderly. 

The Trust is in the process of implementing the recommendations detailed within these two 

confidential enquiries. 

There were no reports published by the Centre for Maternal and Child Enquiries (CMACE) 

during 2010/11. 

There were no reports published by the National Confidential Inquiry into Suicide and 

Homicide by People with Mental Illness (NCI/NCISH) during 2010/11 applicable to the Trust. 

National Institute for Health and Clinical Excellence (NICE) compliance 

A NICE Implementation Group is in place and meets regularly to review new guidance, 

technology appraisals, interventional procedures and other guidance issued by NICE. This 

group also monitors those publications which are relevant for our patients but have yet to be 

fully implemented due to barriers such as funding, training needs or facilities required. This 

ensures that robust action plans are in place and progress is being made towards 

implementation. 

The table below details the number of materials issued by NICE to date and the Trust’s 

status in terms of compliance. For guidelines/guidance which has yet to be fully implemented 

plans are in place to expedite this. 

NICE 

Number issued by end 

of March 2011 

(relevant to JPUH) 

Compliance rate at 

end of March 2011 

Technology Appraisal Guidance 106 88.7% 

Interventional Procedure Guidance 46 71.7% 

Clinical Guidelines 101 73.3% 

Patient Safety Guidance 2 50% 

Public Health Guidance 26 57.7% 



Research 

The number of patients receiving NHS services provided or sub-contracted by the 

James Paget University Hospitals NHS Foundation Trust in 2010/11, that were recruited 

during that period to participate in research approved by a research ethics committee, was 

712. 

Participation in clinical research demonstrates the James Paget University Hospitals NHS 

Foundation Trust’s commitment to improving the quality of care we offer and to making 

our contribution to wider health improvement. Our clinical staff stay abreast of the latest 

possible treatment possibilities and active participation in research leads to successful 

patient outcomes. 

The James Paget University Hospitals NHS Foundation Trust was involved in conducting 

12 clinical research studies in Cancer during 2010/11. It is not possible at the time of 

writing this report to provide data relating to mortality amenable to healthcare/mortality 

rate from causes considered preventable as these studies are not yet completed and the 

data has not yet been analysed. The participation in such studies at the Trust 

demonstrates a commitment to clinical research which it is anticipated will lead to better 

treatments for patients. 

There were 44 (19 nurses and 25 doctors) of clinical staff participating in research 

approved by a research ethics committee at the James Paget University Hospitals NHS 

Foundation Trust during 2010/11. These staff participated in research covering 14 of 

medical specialties. 

In the last three years, we are unaware of any publications that have resulted from our 

involvement in NIHR research as most studies are long term and have yet to complete. It 

is likely that there have been publications generated by Chief investigators from other 

Trusts where we have acted solely as additional research sites. We are largely a trial 

hosting site and are not in receipt of any NIHR grants at present. Our engagement in 

multi-centre studies also demonstrates the James Paget University Hospitals NHS 

Foundation Trust commitment to testing and offering the latest medical treatments and 

techniques. 

Data Quality 

James Paget University Hospitals NHS Foundation Trust will be taking the 

following actions to improve data quality : 

• Monthly meetings with NHS Great Yarmouth and Waveney to discuss data quality 

issues. These are minuted and an action log is maintained to ensure all issues are 

recorded and left open until resolved; 

• Data Quality report to the Information Governance Action Group based on the SUS 

Data Quality Dashboard provided by the Health and Social Care Information 

Centre. This report includes recommendations to the Board which are followed up 

at the next meeting; and 

• Regular reports are sent to the clinical Divisions identifying data quality issues that 

need resolving at source before being submitted to SUS. This is monitored via a 

local reporting system that mirrors the SUS Data Quality Dashboard. 



NHS number and GMC code validity 

James Paget University Hospitals NHS Foundation Trust submitted records during 

2010/11 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics 

which are included in the latest published data. 

The percentage of records in the published data which included the patient’s valid NHS 

number was: 

99.81% for admitted patient care; 

99.80% for outpatient care; and 

99.02% for accident and emergency care. 

The percentage of records in the published data which included the patient’s valid 

General Medical Practice Code was: 

100% for admitted patient care; 

100% for out patient care; and 

98.40% for accident and emergency care. 

This data is based on the latest published figures up to Month 10. 

Information Governance Toolkit 

James Paget University Hospitals NHS Foundation Trust Information Governance Toolkit 

assessment score. Overall score for 2010/11 was 45/45. 

Information governance is a systematic approach to ensuring that all aspects of the 

processing of personal and sensitive information, both paper and electronic, meet 

prescribed standards. It aims to ensure that performance is subject to continuous 

improvement. The Information Governance framework has four dimensions: 

• Management: structures, policies, procedures, etc. 

• Systems: access controls, application security, validation, etc. 

• Processes: protocols, records management, data quality, etc. 

• People: education, training, development, guidance, etc. 

As a key part of the Information Governance agenda, the Department of Health and NHS 

Connecting for Health jointly produced an Information Governance Toolkit. The current 

version of the Toolkit is scored using a simple Red/Green (Satisfactory/Unsatisfactory) 

metric. The Toolkit is designed to assist organisations to achieve the aims of Information 

Governance and currently encompasses: 

• Information Governance Management 

• The NHS Confidentiality Code of Practice 

• The Caldicott Guidelines 

• Data Protection Act 1998 

• Information Security Management NHS Code of Practice 



• Information Quality Assurance 

• Records Management NHS Code of Practice 

• Freedom of Information Act 2000 

It is the tool by which organisations can assess their compliance with current legislation, 

standards and national guidance. The Trust achieved a Level 2 score in 45 of the 45 

requirements in the Toolkit Assessment, which is rated as ‘Satisfactory’ performance. 

Clinical Coding Error rate 5 

James Paget University Hospitals NHS Foundation Trust was subject to the 

Payment by Results clinical coding audit during 2010/11 by D&A Clinical 

Coding Consultancy Limited. The error rates reported in the latest published 

audit for that period for diagnoses and treatment coding (clinical coding) 

were: 

• Primary Diagnoses Incorrect 9.5%; 

• Secondary Diagnoses Incorrect 13.8%; 

• Primary Procedures Incorrect 4.9%; and 

• Secondary Procedures Incorrect 4.5%. 

The table below shows the coding accuracy overall results in comparison to the 2010 

audit. Please note different specialties were audited each year. 

Correct (%) 2009/10 Correct (%) 2010/11 

Primary Diagnosis 92.50 90.50 

Secondary Diagnosis 92.13 86.21 

Primary Procedures 95.83 95.04 

Secondary Procedures 88.89 95.52 

The 2010 audit reviewed the following specialties: 

Gynaecology 

General Surgery 

Trauma and orthopaedics 

Ophthalmology 

General Medicine. 

5 Please note: These results should not be extrapolated further than the actual sample audited. 



What others say about the Trust 

Care Quality Commission 

James Paget University Hospitals NHS Foundation Trust is required to register with the 

Care Quality Commission and its current registration status is registered without 

conditions. 

The Care Quality Commission has not taken enforcement action against James Paget 

University Hospitals NHS Trust during 2010/11. 

James Paget University Hospitals NHS Foundation Trust has not participated in any 

special reviews or investigations by the CQC during the reporting period. 

The Trust has been registered with the Care Quality Commission without conditions since 

April 2010 for the following services: 

• Termination of pregnancies at James Paget Hospital; 

• Family planning at James Paget Hospital; 

• Maternity and midwifery services at James Paget and Lowestoft Hospitals; 

• Diagnostic and screening procedures at James Paget and Lowestoft Hospitals; 

• Surgical procedures at James Paget Hospital; and 

• Treatment of disease, disorder or injury at James Paget and Lowestoft Hospitals. 

Patient Environment Action Team (PEAT) 

The table below demonstrates the PEAT results 2011 for environment, food, privacy and 

dignity for each hospital within the Trust. This demonstrates an improvement on the 2010 

scores where the Trust scored ‘good’ in all areas. 

Environment 

Privacy & 

Food Score 

Site Name 

Score 

Dignity Score 

Lowestoft Hospital Good Excellent Good 

James Paget Hospital Good Excellent Good 

Health and Safety Executive (HSE) 

The Trust was visited by the HSE in November 2010 to conduct a routine review of the 

Trust’s Microbiology laboratory. This resulted in a very positive report with only minor areas 

for improvement identified. All of the improvements suggested have since been 

implemented. 

A follow up visit was also conducted in March 2011 to ensure that appropriate actions had 

been taken following a small formaldehyde spillage in Theatres. The inspector was very 

pleased with our response to this incident and closed the investigation without any further 

recommendations. 



Part 3 

Review of Quality Performance 

Patient Safety 

Leading Improvement in Patient Safety (LIPS) 

LIPS is a nationally led safety improvement programme developed and delivered by the 

Institute of Innovation and Improvement. The programme is designed to support NHS Trusts 

to develop robust organisational plans that will facilitate measurable and sustainable 

improvements in patient safety throughout the organisation. 

The Trust’s Patient Safety Project formally commenced in March 2010. It complements the 

national and international drive to make demonstrable improvements that will reduce the 

volume of harm events experienced by patients in our care. In the UK it is currently estimated 

that harm events are experienced by 1 in 10 patients (National Patient Safety Agency - 

NPSA 2007). LIPS offers a variety of improvement tools to help increase capacity and 

capability to make these achievements. In particular, we are using the Model for 

Improvement as a framework for setting the objectives and targets of the overall project plan. 

This is complemented with the use of Plan, Study, Do and Act (PDSA) cycles as a means for 

performing small tests of change prior to more wide scale implementation. 

Following thorough analysis of local incident data and exploration of relevant national and 

regional driving forces, improvement aims for the Trust were agreed. These have been 

categorised as high level and system level aims. 

High Level Improvement Aims 

• Year on year reduction in harm events of at least 10% 

• Overall reduction in harm events of ≥ 50% over five years 

• 25% reduction in all falls by March 2011. 

10 work streams have been set up to deliver the high level aims. The work around Falls 

prevention has been described in part 2. The other metrics are detailed below. 

Metric 2 – Pressure Ulcer Prevention 

National Context: 

High Impact Actions (2010) estimated 4 -10% of patients admitted to hospital experience a 

pressure ulcer grade 2 6 or above. 

Local Improvement Aim (and CQUIN): 

1. 25% reduction of the 2009/10 baseline of hospital acquired grade 2 and above. 

2. 60% of all inpatients receive Waterlow risk assessments on admission. 

6 There are four recognised grades of pressure ulcers in the European Pressure Ulcer Advisory Panel (EPUAP) 

Wound Classification system which health professionals use to describe the severity of pressure ulcers. 



Current Position: 

Inpatient Pressure Ulcers Grade 2 and above (inc.'not stated April and May 10) 

25 


20 

15 

10 

20 

19 

18 

17 17 

16 

16 

13 

14 

13 13 


13 

12 

14 

13 13 

14 

13 13 13 13 13 13 

10 

9 

8 

Grade 2 

Grade 3 

Grade 4 

Practice Development 

Trajectory 

5 

0 

0 0 0 0 0 0 

1 

0 0 1 

0 0 0 0 



During March 2011 87.6% of patients had a pressure ulcer risk assessment (Waterlow) on 

admission. 

Successes: 

• Significantly raised awareness 

• Review of evidence base 

• Review of Trust documentation 

• Working on the principle of 8 Key Responsibilities for pressure ulcer prevention 

• Revised documentation in all ward areas 

• Communication cascade regarding pressure ulcer prevention care 

• Hospital at Night team link nurse involvement – promotion of standards 24/7 

• Dedicated resource to support change process 

• Inclusion of pressure ulcer prevention training as part of Trust Practice Development 

Training Programme. 

Concerns: 

• Reporting system(s) ineffective 

• Under reporting 

• Inaccurate reporting 

• Under use of the mattress loan store 

• Pressure ulcer classification tool used inaccurately 

• Volume of patients admitted with existing pressure ulcer. 





Metric 3 – Venous Thromboembolism (VTE) 

An all Party Parliamentary Thrombosis Group in 2005 estimated there were 25,000 

preventable deaths per annum nationally due to VTE. 

Local Improvement Aim (and CQUIN) 

1. 90% of patients receive an admission VTE risk assessment. 

2. 80% of inpatient and obstetric patients receive appropriate thromboprophylaxis. 

Current Position: 

VTE Risk Assessment Compliance Rates 2010/11 

100 

90 

80 

70 

% Compliance 

60 

50 

40 

Monthly Compliance 

Trajectory % 

30 

20 

10 

0 

Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 


Data collected from medication charts indicates a consistent achievement of between 90- 

95% compliance with appropriate thromboprophylaxis prescribing. 

Successes: 

• The Trust has achieved VTE Exemplar Site status 

• Bespoke IT system developed to register risk assessment completion 

• Inclusion of VTE on induction and mandatory training 

• General raised awareness of VTE 

• Attendance at external training attendance 

Concerns: 

• Delays in registration of risk assessment 

• Variation in compliance with risk assessment completion 

• Process for supporting Waveney GPs when patients are transferred to Lowestoft 

Hospital 

• Lack of resources within Patient Safety Team to support implementation of remaining 

NICE VTE Quality Standards. 



Metric 4 – Documentation and Record Keeping 

“The purpose of a medical record is to provide a clear account of patient management so as 

to facilitate current treatment and to establish a reliable past medical history and thereby 

provide healthcare professionals with evidence supporting the adequacy of their care”. 

Guidance provided by John Chapman, Trust Solicitor, June 2010 

Local Improvement Aims: 

1. Documentation will be multidisciplinary by the end of March 2012 

2. Format and style enables each episode of care to create chronological history 

3. Complete review of nursing documentation. 

Successes: 

• Essentials of nursing care record sheet trial completed and roll out commenced 

January 2011 

• Specific care plans completed for falls, pressure ulcer prevention and tracheostomy 

• Specific pieces of documentation being reviewed e.g. fluid charts, observation chart 

• Early stages of drafting multidisciplinary record 

• Standardising ‘inpatient episode’ folder throughout Trust 

• Multidisciplinary engagement. 

Excellent progress continues to be made with the development of a multidisciplinary 

healthcare record. Significant changes have been introduced to nursing documentation. The 

principle is to simply but effectively evidence the patient’s journey and their individual care 

needs. The notion that the reliability of a safety intervention is increased by standardising 

and reducing variation has been applied to all new pieces of documentation that guide 

practice. The aim is that all patients, regardless of where their care is being delivered, should 

receive consistent standards of essential care that is generic to the majority of patients in 

hospital. 

Metric 5 – Infection Prevention 

Matching Michigan is a quality improvement project based on a model developed in the 

United States which, over 18 months, saved around 1,500 patient lives. It took place at 

Intensive Care Units (ICUs) in Michigan and introduced technical interventions (changes in 

clinical practice) and non-technical interventions (linked to leadership, teamwork and culture 

change). When applied together they have been shown to significantly reduce the incidences 

of Central Venous Catheter bloodstream infections (CVC-BSIs). 

The Matching Michigan target is no more than 1.4 CVC – BSI per 1000 catheter days. 



Monthly CVC BSI Rates 

14 

12 

Rate of CVC BSI 1000 Catheter days 

10 

8 

6 

4 

Series1 

2 

0 

Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 

Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 

Surviving Sepsis is a campaign that has been introduced to reduce mortality and morbidity 

associated with delays in recognition and treatment of sepsis. If not treated in a timely way, 

sepsis can become a medical emergency. Evidence suggests that a specific bundle of care 

interventions, initiated at point of diagnosis improve patient outcomes. The Trust focus at the 

current time is to improve sepsis recognition. Initiation treatment is being focussed on A&E 

and EADU. Plans are in place to roll out the ‘sepsis bundle’ throughout the Trust this year. 

Surgical Site Infection Surveillance is mandatory, with periodic surgical site surveillance 

undertaken following hip and knee joint replacement surgery. Results issued last year report 

that over the preceding five year period the following infection rates were seen: 

• national average for hip replacement 1.1% (JPUH = 1.2%) 

• national average for knee replacement 1.1% (JPUH = 1.3%) 

Some changes to practice have been implemented that should further improve wound care in 

the orthopaedic areas. 

World Health Organisation (WHO) Surgical Safety Checklist - In England and Wales, 

129,419 incidents relating to surgical specialities were reported to the NPSA from 1 st January 

– 31 st December 2007. The WHO Surgical Checklist is designed to reduce the number of 

errors and complications resulting from surgical procedures. There are ten core standards 

that WHO recommend should remain, even if local adaptation to the checklist is made. At the 

James Paget we have integrated the checklist into our electronic theatre information system 

and have introduced a visual prompt in each. Audit results from October 2010 to March 2011 

demonstrate that more than 99% of the checklist has been appropriately completed. 



Metric 6 – Mortality and Case Note Reviews (using Global Trigger Tool) 

50% of harm events are thought to be avoidable (NPSA 2007). The use of triggers to identify 

adverse events during a manual record review has been used extensively to measure the 

overall level of harm in health care organisations. 

Local Improvement Aims: 

1. 100 baseline random mortality reviews to be completed by end March 2010. 

2. 40 baseline random case note reviews (harm events) to be completed by end March 

2010. 

3. 20 random mortality reviews to be completed every month from April 2010 onwards. 

4. 20 random non mortality case note reviews to be completed every month from April 2010 

onwards. 

Successes: 

• Excellent learning opportunities identified 

• Highlighted trends that are being incorporated into improvement projects e.g. delays in 

appropriate escalation of concerning patients, poor fluid management and completion of 

fluid charts, poor clinical record keeping 

Concerns: 

• Medical capacity to commit to review process 

• Overlap with existing mortality review groups 

• Timely administrative process to arrange reviews. 

Metric 7 – Medicines Management 

Between September 2006 and June 2009 27 deaths, 68 severe harms and 21,383 other 

patient safety medicines incidents were reported to the NPSA nationally. 

Local Improvement Aim: 

1. Ensure reasons for drug admissions are appropriately documented on the drug chart 

2. Improve pain management processes and patient outcomes 

3. To evidence other medicines management actions required from adverse event trends. 

Successes: 

• Multidisciplinary focus 

• Working on the principle of 7 key responsibilities for medicines management 

• Working directly with Medicines Management Action Group. 

Concerns: 

Although progress has been made there is room for further improvements. As a result 

medicines management will have a more targeted focus in the forthcoming year to identify 

ideas and innovations and how we can make more of a difference. 



Metric 8 – Nutrition & Hydration 

Malnutrition (in the form of under nourishment) affects over 3 million people in the UK. It is 

often unrecognised and untreated. This metric links very closely with the deteriorating 

patient project work stream and the Trust’s dementia care project. 


1. Malnutrition Universal Screening Tool (MUST) Nutritional Risk Assessment completed 

on admission 

2. MUST Nutritional Risk Assessment reviewed at least every seven days 

3. 100% of patients who require food/fluid charts have them completed correctly 

4. 100% compliance with the Trust’s Nil By Mouth policy. 

Successes: 

• Building on work of Trust Nutrition Group and Nutrition Link Group 

• Multi disciplinary focus 

• Linking in with Trust Dementia project 

• ‘Hospital at Night’ link nurse involvement to promote the standards 24/7. 

Concerns: 

Improvements have been made. However the standards required remain unmet and work to 

further improve outcomes from this metric will be more targeted in the coming year. This will 

involve a complete review of some of the systems we currently have in place to manage and 

prevent malnutrition/dehydration and ensure we reliably deliver best practice nutritional care. 



Metric 9 – Executive Leadership Patient Safety Walk Rounds 

National Perspective: Executive Leadership Patient Safety Walk Rounds are a nationally 

and internationally recognised methodology for increasing engagement with frontline staff on 

issues that impact on their ability to provide care in a safe environment. 

Local Improvement Aim (CQUIN): 

1. A minimum of 24 walk rounds to be performed during 2010/11 

2. Up to three safety actions will result from each walk round. 

The target of 24 walk rounds has been significantly exceeded and the benefits are 

noticeable. In particular the presence of Executive and Non Executive Directors on the shop 

floor has made staff feel they are being given an opportunity to share their experiences 

regarding patient safety. 

Patient Safety team 

Metric 10 – Observations and the Deteriorating Patient 

National Context: 

Clinical deterioration can occur at any time in a patient’s illness but is more common 

following an emergency admission, during recovery from serious illness and following 

operations. 


1. Increase compliance with observation policy to 100% by end December 2010 

2. Increase compliance with Early Warning Score (EWS) escalation to 100% by end July 


The improvement aims for this metric have not been achieved in the timescales originally 

agreed. However, the aims and objectives of this work stream were reviewed part way 

through 2010 to establish if the targets we had set ourselves were realistic and achievable. It 

was agreed that the timescales should be extended and since that time good progress has 

been made with the vital sign and EWS observations elements of this metric. 



Patient Safety Incidents 

As at 18 th May 2011 the graphs below detail the number and type of adverse incidents 

reported via the Trust internal reporting mechanisms. 

350 

PSI Incidents 10/11 

Number of PSI Incidents 

300 

250 

200 

150 

236 

303 

242 

265 266 

244 

272 

281 

234 

288 

194 

205 

100 

01.04.10 to 31.03.11 (Total Number = 3030) 

50 

0 



PSI Incidents by Category 

1200 

01.04.10 to 31.03.11 (Total = 3030) 

1065 

1000 


800 

600 

400 

200 

0 

2 

255 

99 

127 

66 

6 

71 

47 

5 

133 

5 

80 

16 

247 

2 

122 

1 

403 

172 

7 28 

8 

63 

Anaesthetics 

Assessment,Diagnosis,Scans,Tes 

Consent, Confidentiality,Commu 

Health & Safety 

Information Governance 

IT 

Medical Equipment (Electrical) 

Neonatal 

Paediatrics (Inc Community) 

Records Management 

Security And Fraud 

Theatres (Inc Anaesthetics) 

Cause Group 

All adverse incidents are investigated to ascertain the root causes and appropriate 

improvement actions are then taken. 



For all Serious Untoward Incidents (SUIs) a full root cause analysis investigation is 

undertaken and a detailed action plan is developed and monitored to ensure that any 

learning is implemented into practice across the Trust. The number and type of SUIs 

reported to the PCT and Strategic Health Authority during 2010/11 are set out below. 

SUI's 10/11 

6 

01.04.10 to 31.03.11 (Total Number = 

29) 

5 

5 

4 

4 


3 

2 

2 

3 

2 

3 

2 

3 3 

1 

1 

1 

0 



SUI's by Category 

12 

10 


10 


8 

6 

4 

2 

2 

3 

5 

1 1 1 1 

4 

1 

0 

Appts, Admission, Discharge, T 

Assessment,Diagnosis,Scans,Tes 

Clinical/Medical Treatment/Pro 

Consent, Confidentiality,Commu 

Infection Control 

Information Governance 

Cause Group 

Medicines Management (Inc Gase 

Patient Care,Monitoring, Revie 

Records Management 

Slips, Trips And Falls 



Never Events 

Never Events are serious, largely preventable patient safety incidents that should not occur if 

the available preventative measures have been implemented. 

The core list of Never Events for 2010/11 is detailed. This has been increased to a list of 25 

for 2011/12: 

• Wrong site surgery 

• Retained instrument post-operation 

• Wrong route administration of chemotherapy 

• Misplaced naso or orogastric tube not detected prior to use 

• Inpatient suicide using non-collapsible rails 

• Escape from within the secure perimeter of medium or high secure mental health 

services by patients who are transferred prisoners 

• In-hospital maternal death from post-partum haemorrhage after elective caesarean 

section 

• Intravenous administration of mis-selected concentrated potassium chloride. 

The Trust has introduced a number of control measures to prevent Never Events from 

occurring. However, during 2010/11 there were two Never Events, both of which involved 

the retention of a small swab following suturing after an instrumental vaginal delivery. A 

detailed programme of training, awareness and checklists has now been introduced to 

prevent a similar occurrence in the future. An audit will be conducted during summer 2011 to 

ensure these improvements have been embedded into practice. 

Case Study: Patient Fall (SUI) 

Incident: Patient found on the floor beside the bed having been recently transferred from 

the admissions unit (within one hour of transfer). Patient was diagnosed with a fractured 

neck of femur (broken hip). The family were informed and the incident was investigated 

formally using Root Cause Analysis techniques. 

Findings: Patient was transferred into the ward at lunchtime when staff were busy with 

medicine administration and feeding patients, hence all falls prevention options were not 

considered upon admission. 

Improvements: 

Patients at high risk of falls are now cohorted into one bay and staff are allocated to monitor 

the patients (additional staff are booked). 

Staff are encouraged to consider the use of falls prevention equipment such as falls beds 

and sensocare equipment. 

Falls risk assessments are conducted on admission and then weekly; each bay has an 

allocated day for the assessment to be completed which is advertised at the end of each 

bay. 



Patient Safety Alerts 

At the time of this report the Trust is compliant with all patient safety alerts which are 

monitored by the Central Alert Service. The Trust has a robust process in place for ensuring 

that alerts are received and circulated to the relevant individuals promptly so that any 

necessary actions can be taken within the timescales prescribed. 

NHSLA and CNST 

The Trust was assessed and achieved NHS Litigation Authority (NHSLA) Level 2 in May 

2008. The Trust will be reassessed against the 2011/12 standards for acute trusts in early 

May 2011 when it is hoped that Level 2 will be retained. 

The Maternity Service was reassessed in March 2011 against the Clinical Negligence 

Scheme for Trusts (CNST) 2010/11 Maternity Standards. The service achieved Level 2 

against these standards. 

Clinical Outcomes and Effectiveness 

Accountability Framework – Nursing Care Metrics 

A key piece of work undertaken by the Chief Matron and the Patient Safety Project Director, 

to support the aims of the Patient Safety project, has been the development of an 

Accountability Framework for nursing staff. The primary aim of the framework is to provide 

clarity for staff regarding the standard of practice that is expected. Secondly, that any 

variation in the standards of care our patients receive will reduce, and our organisational and 

departmental approaches will become appropriately standardised. 

The framework consists of 15 Care Metrics within which there are 77 evidence based Key 

Performance Indicators (KPIs). Performance is monitored on a monthly basis via audit data 

collection. Feedback is provided to the relevant Ward Manager and Matron. The first audits 

took place in November 2010 and this data has been used as the baseline. As expected, the 

first set of results were variable amongst the different areas included. However, it is already 

evident that Ward Managers are embracing the concept of the framework as a tool to 

strengthen their team’s performance and capability to improve patient outcomes. 

Once we have established and embedded the Nursing Accountability metrics and KPIs into 

practice we will introduce a further set of metrics at ward level that will reflect other patient 

sensitive areas where Allied Health Professionals and medical colleagues lead e.g. 

medicines management and documentation. In addition we need to ensure that the Nursing 

Accountability Framework links clearly with the Divisional performance score cards and 

performance meetings led by the Director of Finance and Performance. 



Existing Commitments and National Priorities 2010/11 

2009/10 2009/10 2010/11 2010/11 

Target Performance Target Performance 

Total Time In A&E : 4 hours or Less 98% 98.34% 95% 97.21% 

Cancelled Operations 0.80% 1.04% 0.80% 0.52% 

Delayed Transfers of Care 

No Target set 

by CQC 1.50% 3.50% 2.25% 

Access To GUM Clinics: offered an 

appointment within 48 hours 98% 100% 100% 100% 

Access To GUM Clinics: Seen within 

48 hours 95% 96% 95% 96.68% 

Time To Reperfusion For Patients who 

have had a heart attack 

Rapid Access Chest Pain Clinic 98% 

99% 

No >26wk 

Elective Inpatient Waiting Times 

waits 0% 

No >13wk 

Outpatient Waiting Times 

waits 

0% 

100% 99.5% 

All Cancers - 2 Week Wait 93% 93.21% 93% 97.17% 

2 Week Breast symptoms urgent 

referral to first outpatient appointment 

waiting times 93% 

96.91% 

All Cancers - 1 Month Diagnosis To 

Treatment 96% 100% 96% 

99.35% 

All Cancers - 2 Month GP Urgent 

Referral To Treatment 85% 90.92% 85% 

88.37% 


Treatment Of Anti Cancer Drug 

100% 

Regimen 98% 


Treatment Of Surgery 94% 100% 

All Cancers - 2 Month From Consultant 

Upgrade to Treatment 86% 91.18% 

All Cancers - 2 Month From Screening 

Services Referral To Treatment 90% 98.37% 

Incidence of MRSA 10 4 4 2 

Incidence of Clostridium Difficile 60 36 35 29 

18 Week Referral to Treatment: 

Admitted Patients (at March) 90% 90.92% 90% 94.50% 



2009/10 

2009/10 

Performance 

2010/11 2010/11 

18 Week Referral to Treatment: Non 

Admitted Patients (at March) 95% 97.82% 95% 99.06% 

Smoking during pregnancy - data 

completeness 95% 97% 95% 98.12% 

Smoking during pregnancy 29.03% 26.31% 

Patient Experience 

National In-patient Survey 2010 

476 responses were received which equates to 57% of surveys distributed. 

Question Area 

Admission 

The Hospital and Ward 

Doctors 

Nurses 

Care and Treatment 

Operations and 

Procedures 

Leaving Hospital 

Overall 

Conclusions 

Trust scores in relation to other Trusts on patient admission are 

generally higher. 

Overall Trust scores on patient admission issues have fallen back since 

last year. 

Trust scores in relation to other Trusts on issues relating to the hospital 

and ward environment are mixed. 

Overall Trust scores on hospital and ward environment issues have 

improved since last year. 

Trust scores in relation to other Trusts on issues relating to doctors are 


Overall Trust scores on doctors have fallen back since last year. 

Trust scores in relation to other Trusts on issues relating to nurses are 


Overall Trust scores on nurses have fallen back since last year. 

Trust scores in relation to other Trusts on issues relating to care and 

treatment are generally higher. 

Overall Trust scores on care and treatment have fallen back since last 

year. 

Trust scores in relation to other Trusts on issues relating to operations 

and procedures are generally lower. 

Overall Trust scores on operations and procedures have fallen back 

since 

last year. 

Trust scores in relation to other Trusts on issues relating to leaving 

hospital are generally lower. 

Overall Trust scores on leaving hospital have improved since last year. 

Trust scores in relation to other Trusts on issues relating to the patients’ 

overview of their stay are generally lower. 

Overall Trust scores on the patients’ overview of their stay have fallen 

back since last year. 

The following chart shows the range of responses on some key questions in the survey. It 

shows three things: 

• The range of scores achieved by all Trusts surveyed by Quality Health on a 

particular group of questions. The range is graded from green to red. 

• The national mean score achieved by all Trusts for each of the questions. This is 

shown as a blue arrow pointing toward each scale. 

• The Trust’s score on each key question. This is shown on the scale as a yellow 

diamond. 

The national mean score and the Trust’s score is shown without any weighting or 

standardisation of the data. 



Our best scores (15 areas) – the Trust scored in the top 20% of acute trusts in England for 

the following: 

• Being treated with respect and dignity 

• Having enough privacy when being examined or treated 

• Patient feeling they waited the right amount of time on the waiting list 

• Patients not having their admission date changed 

• Short length of time to get to a bed on the ward 

• Not sharing a sleeping area with patients of the opposite sex 

• Cleanliness of ward areas 

• Cleanliness of toilets and bathrooms 

• Rating hospital food as very good 

• Patients being given enough help from staff to eat their meals 

• Patients having confidence and trust in the nurses 

• Patients having confidence and trust in the doctors 

• Nurses washing hands between patients 

• Having enough privacy when discussing condition or treatment 

• Not needing to complain about their care in hospital. 



An action plan has been developed for those areas where the Trust scored less well: 

Issue 

For being bothered by noise at 

night from staff 

Action 

Continue with initiatives commenced in 2010: ear plugs 

offered at night to suitable patients and a regular noise 

audit. 

Information to be placed in patient lockers to raise patient 

awareness. 

For always being offered a 

choice of food 

Staff completely explaining 

how the operation had gone in 

a way the patient could 

understand 

To review menu provision on EADU to implement normal 

ward menu and increase choice offered. 

Staff reminded to check patient understanding following 

information giving (Remember I’m a patient leaflet) 

Values (customer care) training 

Encourage patient responsibility through posters in clinics/ 

ward areas ‘Have you understood what was said to you? 

Do you need to ask again/do you need to ask any other 

questions?’ 

Staff completely telling 

patients how they would feel 

after the operation/treatment 


risks and benefits before the 

operation 


what would happen during 

operation/treatment 

Staff completely answering 

questions before the operation 

in a way the patient could 

understand 

Staff completely telling 

patients what danger signals to 

watch for at home 

Staff completely giving family/ 

someone close to the patient 

information on how to help care 

for them 

Patient being asked to give 

their views on care quality 

As above 

As above 

As above 

As above 

Posters to be developed: ‘Red means danger – if the 

wound feels hot or red following the procedure contact the 

ward or GP’ 

Review discharge leaflets. 

Pilot information: ‘Discharge from hospital into care setting’ 

– covering medications, diagnosis, skin condition, 

treatment to be adapted for family/carer use. 

Add information to website asking patients to give their 

views on the quality of care using the PET devices. 

Link to NHS Choices website on Trust website. 



Experience Based Design 

Experience based design (EBD) is a method of designing better experiences for patients, 

carers and staff and captures the experiences of those involved in healthcare services. The 

approach has been produced through the work of the NHS Institute for Innovation and 

Improvement (www.institute.nhs.uk/ebd) working in collaboration with NHS organisations and 

external agencies. This approach focuses on the experience of care. 

Experience based design uses four key steps: 

1. Capture the experience; getting patients and staff involved 

2. Understand the experience; identifying emotions, mapping highs and lows, finding 

touchpoints 

3. Improve the experience; co-design, turning experience into action; and 

4. Measure the improvement; evaluate and sustain the improvement. 

Trust staff were invited to approach patients to ask if they would like to be involved in the 

work to improve their experience of care at the Trust. Norfolk LINks, Suffolk Family Carers, 

Deaf Connexions and Norfolk and Norwich Association for the Blind were also approached 

for interested participants. This resulted in 25 staff and 14 patients/carers attending an 

experience event. 25 staff and patients were also involved in co-design events. 

Feelings and experience were captured by asking everyone to complete an experience 

questionnaire. This questionnaire is a tool to gather people’s emotions at certain points along 

the patient journey through the hospital. We adapted the questionnaire to reflect the inpatient 

journey and the out-patient journey so patients could share their experiences of either 

or both. The staff were asked to reflect on how they felt about the care they gave at particular 

points along the patient journey. 

Separate staff and patient events were held followed by a joint co-design event where the 

results were discussed, collated, themed and ranked. 

The findings were merged into three main action groups: 

1. Special needs training/carer involvement 

2. Environment/car parking 

3. Communication/attitudes/team working/resource pressures/clinics/technology 

The information gained has been fed into a number of Trust projects/action plans: 

• Carer involvement links into the Dementia project 

• Mental health training and special needs training for staff 

• Values and Customer Care training 

• Understanding how Choose & Book works and patient information 

• Car parking 

• Discharge information given to patients. 



Maternity National Survey 

The response rate for the Trust was 47% (116 usable responses from a final sample of 245). 

Question Area Conclusions Recommended Actions 

Early Pregnancy 

Antenatal Check-ups 

Tests and Scans 

During Pregnancy 

Trust scores in comparison to other 

Trusts on issues relating to care at 

the start of pregnancy are more 

positive. 

Trust scores on issues relating to 

care at the start of pregnancy have 

improved compared to 2007. 


Trusts on issues relating to 

antenatal check-ups are more 

positive. 


antenatal check-ups have improved 

in respect of staff continuity 

compared to 2007. 


Trusts on issues relating to tests 

and scans are about the same. 


Trusts on issues relating to care 

during pregnancy are mixed. 


care during pregnancy have 

remained about the same compared 

to 2007. 

Increase the number of women who 

are given a choice of where to have 

their baby including a home birth. 

Ensure that information is given 

about the choices available to women 

on where to have their baby. 

Ensure all women who need one are 

given a copy of The Pregnancy Book. 

Ensure that all women are given 

information about the NHS Choices 

website. 

Ensure that women are given as 

much choice as is possible about 

where they have their antenatal 

check-ups and who will do them. 

Increase continuity of care from 

midwives so that women see the 

same midwife as often as possible. 

Look at ways of increasing the 

continuity of care from hospital 

doctors so that women see the same 

doctor as often as possible. 

Ensure that all women have a choice 

about whether they have a screening 

test for Down’s syndrome. 

Take action to improve explanations 

about the reasons for testing for 

Down’s syndrome. 

Ensure that women get clear 

explanations about the reasons for 

dating scans and mid-trimester scans 

and feel they have a choice about 

having these scans. 

Ensure that all women are given a 

contact number in case they are 

worried during their pregnancy. 

Ensure that both verbal and written 

information is easily understood by 

women, and that all information and 

explanations required are given. 

Ensure that all women are treated 

with respect and dignity, kindness 

and understanding during their 

pregnancy. 

Ensure that women are involved as 

much as possible in decisions about 

their care. 




Antenatal Classes 

During Labour 

The Baby’s Birth 


Trusts on issues relating to 

antenatal classes are more positive. 


antenatal classes have improved 



Trusts on issues relating to labour 

are about the same. 

The Trust score on getting the pain 

relief wanted has remained about 

the same. 


Trusts on issues relating to the birth 

of the baby are about the same. 

Review the provision of NHS 

antenatal classes given the high 

proportion of women not attending 

NHS classes and in particular, those 

not attending any classes at all. 

Examine alternative times and places 

for classes given the number of 

women saying they were not 

convenient. 

Ensure that women are told when 

partners/others can attend classes 

with them. 

Ensure that there are enough classes 

to meet women’s needs. 

Ensure that women are given a 

choice as far as is possible about 

whether they are induced. 

Examine ways of increasing the 

number of women able to move 

around and choose the position that 

makes them most comfortable during 

labour. 

Ensure that women are given pain 

relief in a timely manner to meet their 

needs. 

Consider whether the Trust’s level of 

caesarean sections can be brought 

down. 

The Staff 


the birth of the baby have improved 



Trusts on issues relating to the staff 

are mixed. 


the staff are mixed compared to 

2007. 

Ensure that women are cared for by 

the same midwives as far as is 

possible during labour and the birth 

of their baby and if possible by 

midwives they have met previously. 

Ensure that husbands and partners 

are able to be present for the whole 

of labour and the birth of the baby if 

requested. 

Examine reasons why some women 

feel they are left alone at times which 

they find worrying. 



women, and that all the information 

and explanations required are given. 



and understanding during labour and 

the birth of their baby. 




Post-natal Hospital 

Care 

Feeding Baby 

Care at Home After 

Birth 


Trusts on issues relating to hospital 

care after the birth are more 

positive. 


hospital care after the birth have 

fallen back compared to 2007. 


Trusts on issues relating to feeding 

baby are less positive. 


feeding baby have remained about 

the same compared to 2007. 


Trusts on issues relating to care at 

home 

after the birth are more positive. 


care at home have improved in 

respect of the overall rating of care 


Examine ways of increasing the 

number of women who feel involved 

in decisions about their care during 

labour and the birth of their baby. 

Examine reasons why some women 

think their stay in hospital was too 

short. 

Ensure that women are given all the 

information they require about their 

own recovery after the birth of their 

baby. 

Ensure that all babies have a 

newborn examination before 

discharge. 



women, and that all the information 

and explanations required are given. 



and understanding during their 

postnatal stay in hospital. 

Ensure that women have infant 

feeding discussed with them during 

their pregnancy by midwives. 

Ensure that women are given full 

support and encouragement, 

practical help and consistent advice 

about feeding their baby, particularly 

in relation to breast feeding. 

Look at ways of increasing the 

number of women breast feeding 

Ensure that women have a contact 

number in case they are worried by 

anything when at home after the 

baby’s birth. 

Review the number and frequency of 

midwives visits in the light of 

respondents’ views. 

Review the provision of information 

about looking after baby in the light of 

the number of women who say they 

either did not get information or that 

they only got it to some extent. 

Ensure that all women have postnatal 

check-ups for their own health. 



Compliments and Complaints 

As a Trust we are encouraged that our patients, their families 

and visitors can access ways to provide us with feedback and 

we welcome their comments. 

A total of 334 formal complaints were received by the Trust 

during 2010/11 on a range of issues as detailed in the graphs 

below. This equates to 4.2 complaints per 1000 admissions. 

All complaints are seen and responded to by the Chief 

Executive and we regularly review trends and change our 

practices as a direct result of this invaluable feedback. For an 

example of changes to practice following a complaint see case 

study below. 

Complaints 2010/2011 

40 


38 

Number of Complaints 

35 

30 

25 

20 

15 

35 

31 

26 

29 

20 

23 23 

33 

21 

28 

27 

10 

5 

0 



Complaint Issues 2010/2011 

300 

250 

262 

01.04.11 to 31.03.11 (Total Number = 576) 

Number of Complaint Issues 

200 

150 

100 

84 

91 

50 

0 

25 

8 

6 

30 

1 

20 

10 

4 4 1 

16 

1 

7 3 2 1 

Admiss, Disch & 

Trans Arrang 

Aids, Appliance 

Equit, Premise 

All Aspects Clinical 

Treatment 

Appoints 

Delay/cancel (IP) 

Appoints 

Delay/cancel (OP) 

Attitude Of Staff 

Comms/Inf To 

Patients 

Dementia 

Essence Of Care 

Failure To Follow 

Procedures 

Hotel Services 

Infection Control 

Other 

Paitent 

Privacy/Dignity 

Patient 

Discrimination/Status 

Patients Property & 

Expenses 

Personal Records 

(Inc Medical) 

Policy & Systems 

Transport (Amb & 

Other) 

Category Type 



Case Study: Health Service Ombudsman 

During 2010/11 five cases were referred to the Health Service Ombudsman for review. 

None were accepted for investigation. However, one complaint was upheld and investigated by 

the Ombudsman in 2010 although it was reported in 2009. 

The Trust received a complaint from the relatives of a lady who was taken ill whilst on holiday in 

the area. She attended a local GP who telephoned our Emergency Assessment and Discharge 

Unit (EADU) for advice as this lady had a rare congenital disorder. The Consultant gave advice 

over the telephone that the patient should see her specialist on her return home. The patient 

returned home immediately but passed away the next day. 

The family complained and stated the patient died because she was not admitted to hospital for 

assessment. The case was referred to the Health Service Ombudsman who investigated the 

complaint and the complaint was upheld, as the Trust was unable to provide sufficient evidence of 

the conversation between our consultant and the GP on the telephone. 

As a result of the Ombudsman’s report into this complaint the Trust developed an action plan to 

prevent a similar occurrence in the future. This included: 

Telephone Advice: The Trust had no information on the patient because it was a telephone 

enquiry for advice which had not been documented in EADU. The patient was on holiday and 

therefore had no hospital notes. The Trust now utilises the EADU referral forms to document 

telephone advice given to GP's which are retained on the unit. The Trust now ensures that when 

GPs telephone the unit they are given advice regarding what to do if a patient deteriorates, 

including a reminder that GPs are able to admit directly to EADU if they are concerned. 

The Trust accepted the Ombudsman’s recommendations and a copy of the action plan was 

shared with the family, together with an apology. 

A number of complaints were received by the Trust throughout February and March 2011, 

which resulted in some negative media reports, where the standard of care at the Trust was 

being questioned. 

Maintaining the reputation of the Trust, our staff and the services we provide is a priority at all 

times. We have, where possible, provided accurate information to the media without 

compromising patient confidentiality. We have also acknowledged where mistakes have been 

made, apologised where appropriate and agreed on ways forward to resolve the issues. 

We have also received many positive comments and compliments from users of our services 

via thank-you cards, letters, emails and correspondence on the NHS Choices website: 

“What impressed me most was that I was treated as an individual.” 

“Throughout I was nursed with care and compassion.” 

“Thanks for everything. 

I could not have wished for better treatment. 

The staff were great, all of them. 

The Food was excellent. 

The bed was very comfortable. 

The level of care un-surpassable.” 



PALS 

The Patient Advice and Liaison Service (PALS) supports patients, relatives, carers and 

members of the public who need information about the healthcare system. They deal with 

general enquiries about the healthcare services available, resolve problems by identifying the 

right people to talk to and explain how to make a complaint if a concern is unresolved. 

During 2010/11 there were 806 enquiries via PALS, as demonstrated by the graphs below. 

100 

90 

86 

PALS Enquiries 10/11 

01.04.10 to 31.03.11 (Total Number = 

755) 

80 

80 

Number of Enquirers 

70 

60 

50 

40 

56 

64 

67 

61 

63 

60 

38 

48 

65 

67 

30 

20 

10 

0 



Case Study 4: 

Patients and visitors raised with PALS the lack of staff available at lunchtimes to 

give help to patients (to encourage patients with confirmed dementia/or the 

inability to eat their main hot meal). 

Family members sometimes cannot attend during the week, due to work or family 

commitments, and the staff do not always have the time to assist all the patients 

who require one on one support at lunchtimes. With this in mind we decided to 

have mealtime service providers that are given training and liaise with the sister 

on the ward to find out which patients need encouragement or some help. 

Patients who require assistance at mealtimes have red jugs and red trays so they 

can be easily identified. We now have a strong team of nine volunteers that 

attend at lunchtimes Monday – Friday and are in the process of recruiting more 

meal time helpers. 

This will improve the wellbeing of our patients by stimulating and encouraging 

them to eat their main lunchtime meal. This aids a quicker recovery and makes 

the patient’s journey through the hospital that little bit easier for them and their 

families. 



Patient Experience Measures 

Patient experience measures 2009/10 Actual 2010/11 Actual 

PROMS - % of questionnaires completed 

(All surgeries - April to October 2009) 

• Hip replacement surgery 

April to October inclusive rates only available 

• Knee replacement surgery 


• Varicose vein surgery 


• Groin hernia surgery 


Patient Feedback – % patients who would recommend 

this hospital to friends or family 

National Inpatient survey score for cleanliness – 

bathrooms/toilets/wards (Q 22) 

National Inpatient Survey – number of question areas 

where responses are ‘better’ than other trusts 

National Inpatient Survey – number of question areas 

where responses are in the top 20% compared to other 

trusts 

National Inpatient Survey score for dignity and respect 

(Q 72) 

National Inpatient Survey score rating for hospital food 

(Q 28) 

National Inpatient Survey score rating for patients 

experiencing a delay to discharge (Q 61) 

National Inpatient Survey score for patients 

understanding answers to important questions from 

doctors (Q 31) 

Patient feedback – having confidence and trust in the 

staff treating them (Q 32) 

National Inpatient Survey score for length of time on 

waiting list before admission (Q 9) 

April 09 to 75.5% 

October 09 data 

67% 

73% 79.6% 

77% 88.7% 

37% 51% 

40% 65.7% 

80% 2009/10 Local 

PET tool score 8 

out of 10 (80%) 

92 91 

9 0 

‘about the same’ 

on all areas 

34 15 

91 90 

64 63 

73 76 

84 83 

90 91 

87 87 

Formal Complaints – total number 325 334 



Staff Experience 

Staff Survey 2010 

The findings can be summarised as follows: 

• The Trust scored better than its 2009 score and/or than other trusts in 49 questions 

• The Trust scored the same as its 2009 score and/or than other trusts in 14 questions 

• The Trust scored lower than its 2009 score and/or than other trusts in 44 questions 

• The Trust scored better than its 2009 score but lower than other trusts in 10 questions 

The table below details some of the questions within the staff survey and the responses 

received compared to the average score for all other trusts: 

Item 

2010 Trust 

Data 

Work Life Balance 

% of staff working more than 11 unpaid hours a week 2% 3% 

% of staff agree that the Trust committed to helping staff balance 47% 35% 

home and work life 

% of staff who can approach their immediate manager to talk openly 51% 43% 

about flexible working 

% of staff who agree their manager gives clear feedback on their work 43% 38% 

% of staff who agree that team members have shared objectives 62% 62% 

% of staff who agree that the team regularly meets to discuss 

43% 45% 

effectiveness 

% of staff who agree that team members have to communicate closely 55% 57% 

to achieve the team’s objectives 

% of staff who agree that they often think about leaving the trust 16% 20% 

% of staff who agree that they will leave the Trust once they have 5% 9% 

found another job 

% of staff who have seen any errors, near misses or incidents that 18% 21% 

could have hurt staff 

% of staff who have reported a staff error, near miss or incident 43% 52% 

% of staff who have seen any errors, near misses or incidents that 25% 29% 

could have hurt patients 

% of staff who have reported a patient error, near miss or incident 58% 59% 

% of staff who agree that the Trust treats staff who are involved in an 43% 40% 

error, near miss or incident are treated fairly 

% of staff who agree that the Trust encourages staff to report errors, 

near misses or incidents 

68% 66% 

The chart below shows three things: 

Mean score 

for all Trusts 

• The range of scores achieved by all trusts surveyed on a particular group of questions. 

The range is graded from green to red. 

• The National mean score achieved by all trusts for each of the questions. This is shown 

as a blue arrow pointing toward each scale. 

• The Trust score on each question, shown as a yellow diamond. 



• 

100 

Key Scores Comparison 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Trust help 

staff work 

Appraisal/re 

view in last 

Have 

planned 

Disagree 

cannot meet 

conflicting 

Satisfied 

with extent 

Trust values 

Senior 

managers 

Care of 

patients top 

Management 

/ staff 

communicatio 

n effective 

No work 

related 

stress in last 

Local Staff Feedback 

The local Patient Experience Tool (electronic survey device) has been utilised within the 

Trust to ascertain staff opinion and input into a range of areas. The devices have been 

positioned in the staff canteen and main foyer and analysis is pending. 

Involvement 

This Quality Account has been developed in close collaboration with the Governors Council, 

who represent the Trust members, our patients and the local population. 

A draft version of this document was shared with our main commissioners during 2010/11, 

NHS Great Yarmouth and Waveney, the local GP commissioners Health East CIC, Local 

Involvement Networks (LINks) and the Health and Overview Scrutiny Committees for their 

comments. The following statements have been provided by these organisations for 

inclusion in this report. 



Endorsement 

Local Involvement Networks 

Norfolk LINk and Suffolk LINk thanks the James Paget University Hospital Trust 

Board for the opportunity to comment on the Quality Account for 2010 - 2011. 

It was pleasing to see that cognisance had been taken of the previous comments 

made. The report was well presented with appropriate language for the general 

public to understand. 

The Trust is making good use of the national guidelines, CQUINN, and internal 

audits, etc to measure progress against defined targets when assessing progress 

against their four stated objectives of Reduction in Falls/ Reduction in Patient 

Mortality/ Patient Safety/ and Clinical Outcomes and Effectiveness. 

The Trust proposals are built upon the progress of the previous year and utilising 

specific equipment regarding falls throughout the hospital. This approach within the 

Trust and across the locality can only be good for patients and is pleasing to see. 

Improved patient safety has been put as a high value within the work across the Trust 

and this is to be commended. Norfolk LINk and Suffolk LINk look forward to the 

improved patient experience across the Trust. 

Internal audits are essential for the improvement of services. 

Norfolk LINk and Suffolk LINk are pleased to see the Trust is looking to ensure that 

the NICE Guidelines are embedded in all aspects of the work and commends the 

Trust on its recent good PEAT inspection and other external audits. 

Norfolk LINk and Suffolk LINk look forward to working with James Paget University 

Hospital NHS Foundation Trust in 2011/2012 and hearing of the continued 

improvements in the services that the hospital provides. 

Marion Fairman-Smith 

Suffolk LINk Chairman 

Patrick Thompson 

Norfolk LINk Chairman 

Health Overview and Scrutiny Committee 

The Norfolk Health Overview and Scrutiny Committee has decided not to comment on any of 

the Norfolk NHS Trusts Quality Accounts for 2010/11 and would like to stress that this should 

in no way be taken as a negative statement. 

The Suffolk Scrutiny Committee is confident with the relationships built up with NHS trusts in 

Suffolk over the past year. This work should be developed to ensure delivery of the best 

possible health services for the people of Suffolk. The Suffolk Scrutiny Committee has 

decided not to comment on any of the Suffolk provider NHS trust's Quality Accounts for 

2010/11 and would like to stress that this should in no way be taken as a negative comment. 

The Committee has taken the view that it is appropriate for Suffolk's Local Involvement 

Network (LINk) to consider the Quality Account and comment accordingly. 



NHS Great Yarmouth & Waveney 

NHS Great Yarmouth & Waveney thanks the James Paget University Hospitals NHS 

Foundation Trust for the opportunity to comment on their Quality Account for 2010/2011. 

NHS Great Yarmouth & Waveney confirms that the Quality Account is based on a 

reasonable interpretation of available data. 

The continued involvement of the trust in the NHS Great Yarmouth & Waveney Patient and 

Carer Experience Board was welcomed. Going forward in 2011/12, with NHS Great 

Yarmouth & Waveney’s revised Patient Safety Experience and Quality Committee, we hope 

to build on this partnership with all stakeholders to ensure that patient safety and experience 

are promoted. 

We note the continued reductions in Healthcare Associated Infection, the introduction of 

executive-led patient safety walk-rounds, and the James Paget University Hospitals NHS 

Foundation Trust’s innovation in the 2010/11 CQUIN Programme. We note the embedding of 

the Leading Improvement in Patient Safety Programme. 

The Trust also continued to demonstrate a reduction in Hospital Standardised Mortality Ratio 

rates. We acknowledge James Paget University Hospitals NHS Foundation Trust’s 

involvement in planning for the management of the demand on local services across the 

system. We welcome the continued partnership with James Paget University Hospitals NHS 

Foundation Trust in the Clinical Transformation Board, as the Trust transforms its local 

services through increasing clinical engagement and leadership, and look forward to the 

Trust’s active engagement in the System Leadership Board, whose prime purpose is to set 

the strategic direction for health and social care in Great Yarmouth and Waveney, and 

oversee the delivery of the area’s transformation, governance, QIPP and workforce plans. 

Going forward in 2011/2012 NHS Great Yarmouth & Waveney will encourage clear and 

reported outcome measures for patients. A particular focus will be reducing avoidable harm, 

and ensuring lessons and good practice are shared, through the Leading Improvement in 

Patients Safety Programme, and the analysis of patient experience, clinical incidents and 

complaints. 

The Board of NHS Great Yarmouth & Waveney will continue to monitor and review all 

relevant providers against the Mid-Staffordshire recommendations, the Ombudsman’s Report 

‘Care and Compassion and Maintaining Quality Through Transition’ and associated 

initiatives, and note that the Board of Directors of James Paget University Hospitals NHS 

Foundation Trust is monitoring this key area. 

NHS Great Yarmouth & Waveney look forward to encouraging further quality achievements 

in 2011/2012 with James Paget University Hospitals NHS Foundation Trust and to receiving 

the next Quality Account. 

Andrew Morgan 

Chief Executive 

NHS Great Yarmouth and Waveney 

Governors Council 

This report shows that in spite of an increasingly aged population, a great increase in the 

number of emergency admissions and having to make vast financial savings, the Trust 

continues to deliver an excellent service of a high standard to the majority of its patients and 

provides a good working environment for its staff. 

In any organisation there are bound to be criticisms and it is note worthy that the number of 

formal complaints has increased this year. However, it is important that people make known 



their concerns so that the matters can be investigated and actions put in place to make 

certain they do not recur. 

The Governors have been particularly keen that the patient should come first in all matters 

and this has been taken on board by the organisation. Much time and effort has been put 

into improving the patient’s experience and care and it is good to see that again national 

surveys have shown that in the majority of measures the Trust remains in the top 20% of 

trusts. Where this is not the case action plans have been developed to improve the 

performance. 

Each year the number of emergency admissions increases and this has been particularly 

severe this year. As a result, nearly 600 elective operations were postponed. This is very 

distressing for patients and their carers and puts added strain on all grades of staff. In 

addition, extra time and money has to be spent to find alternative times to perform these 

operations. Enabling the admission of patients for elective operations without cancelling 

emergency admissions is one of the biggest challenges facing the Trust. 

In spite of these pressures the Hospital Standardised Mortality Ratio remains low indicating 

an overall very good standard of care. 

In these particularly challenging times the Trust is to be congratulated that it has managed to 

maintain its high standards – and in some instances to improve upon them. The Governors 

welcome the frequent and open exchanges which they have with management and are 

pleased to play their part in helping to maintain and improve standards. 



Glossary of Abbreviations 

A&E 

C diff 

CMACE 

CQC 

CQUIN 

CRT 

EWS 

GUM 

H@N 

HFEA 

HSE 

HSMR 

ICAS 

IHI 

IOG 

LINks 

LIPS 

LOS 

MCDC 

MUST 

NCEPOD 

NCISH 

NHSLA 

NICE 

NIHR 

NSF 

PCT 

PEAT 

PET 

PROMs 

QIPP 

SUS 

SWIFT 

TIA 

TTO 

VTE 

Accident and Emergency Department 

Clostridium difficile 

Centre for Maternal and Child Enquiries 

Care Quality Commission 

Commissioning for Quality and Innovation 

Customer Research Technology 

Early Warning Score 

Genitourinary medicine 

Hospital at Night 

Human Fertilisation & Embryology Authority 

Heath and Safety Executive 

Hospital standardised mortality rate 

Independent Complaints Advocacy Service 

Institute for Health Improvement 

Improving outcomes guidance 

Local Involvement Networks 

Leading Improvement in Patient Safety programme 

Length of stay 

Marie Curie Delivering Choice programme 

Malnutrition Universal Screening Tool 

National Confidential Enquiry into Patient Outcome and Death 

National Confidential Enquiry into Suicide and Homicide 

National Health Service Litigation Authority 

National Institute for Health and Clinical Excellence 

National Institute of Health Research 

National Service Framework 

Primary Care Trust 

Patient Environment Action Team 

Patient Experience Tool 

Patient Reported Outcome Measures 

Quality, Innovation, Productivity and Prevention 

Secondary Uses Service 

Strategic Workforce Investment Fund for Tomorrow 

Transient Ischaemic Attack 

To Take Out (medications) 

Venous thromboembolism

Quality Account 2010/11 - James Paget University Hospitals

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